involvement of hub nurses in hiv policy development

Research on Humanities and Social Sciences www.iiste.org

ISSN 2224-5766(Paper) ISSN 2225-0484(Online)

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Involvement of Hub Nurses in HIV Policy Development: Case Study

of Nyanza Province, Kenya

Akunja E, Kaseje D.C.O, Obago I and Ochieng B.M

Great Lakes University of Kisumu, P.O Box 2224-40100, Kisumu.

*[email protected]

The research was funded by the Teasdale Corti program and Great lakes university of Kisumu

Abstract

Nurses constitute the bulk of healthcare personnel in most countries playing major responsibility of providing quality

care. Few nurses are however involved in health policy development yet they play a critical role in providing care for

the individuals infected and affected by HIV/AIDS.

This study describes involvement of nurses in HIV policy development in Nyanza Province Kenya. This study adopted

a case study design using qualitative methods.

Levels of involvement in policy development were identified to be at different levels but still very minimal at the

provincial and national levels. Linkages and collaborations were the greatest benefit in policy development.

Governments have a key role in governing policy issues. NGOs, learning institutions and communities are key players

in health policy. Barrier to participation in policy formulation were identified as competing priorities, inadequate time,

and limited knowledge and skills. Nurses play critical role in HIV/AIDS and therefore they should be involved in

policy formulation.

1. Introduction

Health systems in many countries are currently facing a number of challenges, some of which include limited

evidence-based nursing practice, limited research use, poor healthcare delivery and poor policy uptake and

implementation (World Health Organization, 2002). Consumers and policy makers increasingly demand improvement

in nursing services and expect that developments are grounded in defensible research (Kellner, Wellman, Boon &

Welsh, 2004). Indeed, there has been emphasis on the need for nurses to be involved in policy development (Clark,

2006), which will lead to improved quality of nursing care and the broader health system in which nursing care is

provided (Edwards, et al. 2009 ). However, calls to increase nurses’ involvement in policy development have not been

very successful (Pan American Health Organization, 2004).

There are many compelling reasons to involve nurses in policy development (Edwards et al., 2009). Nursing is a

recognized profession with a growing body of research based evidence informing its practice yet there is a dearth of

nurses involved in health care policy development and reform, especially at a strategic and national level. (U.S

Department of Health and Human Services, 2006). Nurses are the largest group of health professionals, and are in a

unique position to help formulate, implement, and evaluate such policy efforts (Robert Wood Johnson, 2010).

This study attempts to contribute to the knowledge base by exploring the involvement of hub nurses in policy

development. Leadership Hub are a group of health care workers comprised of front-line nurses and nurse managers,

researchers and decision makers. The main purpose of the leadership Hub is to create a sustainable infrastructure for

leadership capacity in research and knowledge translation (research-to-action). There were 3 groups of Hub members

within the project in Kenya all situated in Nyanza province. The Hub members were drawn from different levels of

authority and responsibility within the health system. Hub members were selected by researchers in consultation with



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the national advisory committees, district authorities, and local researchers.

The study examines the level of involvement of leadership hub nurses in policy development, benefits of their

involvements and the barriers to their involvement in policy development.

1.1 Problem statement

The burden of HIV and AIDS care is still borne by nurses and midwives, who are the first point of contact for patients

and other staff members who shoulder significant responsibility for their continuing treatment and care (PAHO, 2004).

Unfortunately, the lack of recognition and respect for their input in policy making is escalating the burden and

frustrating countries’ efforts to control HIV and AIDS epidemic (Armstrong, 2003).

Although nurses are the majority of the health care professional staff in most health systems, and their involvement is

recognized as indispensable to meeting development goals and delivering safe and effective care (Buchanan, 2008),

their participation is minimal if not non-existent in policy development yet they are the ones at the grassroots caring for

the infected and the affected (PAHO, 2004).

1.2 Broad objective

To investigate the involvement of the leadership hub nurses in influencing HIV and AIDS policy and practice.

1.2.1 Specific objectives

To describe the level of involvement of leadership hub nurses in policy development.

To identify and describe the benefits of leadership hub nurses involvement in HIV policy development.

To identify and describe barriers of leadership hub nurses to involvement in policy development.

2. Research Methodology

2.1 Study design

This study used a case study design to examine the process of engaging in policy and practice change through dynamic

collaborations involving and/or led by nurses, focusing on data collected at baseline and mid-term and only in the

intervention districts. This study was conducted in 3 district Kisumu and Nyando in Kisumu County and Suba District

in Homa Bay County which were purposefully selected for this research being that the 3 district were original GLUK

partnership sites and collaborations had already been created, making it easier to carry out the research.

2.2 Data collection

Secondary unpublished data were collected using FGDs tools.

2.3 Study Population

The sample size for the study included total of twenty three participants and were representative of nurses from

different levels which included frontline nurses, nurse managers and decision makers who were purposively sampled.

2.4 Analysis

The data analysis procedure used was adopted from Creswell (2006), which included preparing and organizing data,

reducing and summering the data through the process of coding and presenting the data in narrative form. In this

process, data were entered and summarized with the assistance of NVivo8 qualitative analysis software (QSR

International, 2008). Qualitative content analysis was used to analyze the data which involved counting frequencies to

determine how often categories occurred.



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3. Findings

3.1 Level of involvement within the health systems

Participants recognized that they have been involved in policy issues at different levels of the health systems to include

local levels through to the sub district and district levels. They also appreciated that they are recognized in policy issues

especially at the workplaces. However, they pointed out that it is still difficult to reach the provincial and national

levels. This is evident in the sentiments of participants.

In regard to involvement to policy making, for me I thought that policies were just being made from above, but since I

started attending the HUB project, it came to my mind that some of these policies you can made at your workplace, for

instance the protection policy among staff, which gives me the strength to work even further. (FGD 3)

Locally at the community levels even at our work places we are able to influence policies, for example it is us the

nurses that came up with the home based care policy. At the work place; the DPHN asked for our opinion about what

we need to adjust about the service charter and am happy that our ideas were incorporated that means we are making

progress. However, at the provincial and National levels things are still a little hard but we hope to see a change in

future (FGD 1)

Participants recognized that it is important to identify and share policies with fellow colleagues at the workplaces and

even at different forums where they meet. They acknowledged that to be involved in policy development it is

necessary to identify existing policies that affect one’s work as a health professional. The argument given by

participants is that for effective participation in policy development, it is necessary that one has the knowledge of

existing policies to make effective change.

When we joined the hub, most of us were not interested in these policies and I will agree we felt these policies were

for the district managers, but now we are all interested to learn what policies exists in our workplaces and how we

can make improvement. (FGD 3)

In this hub, we have shared a lot about policies that affect us at the work places. We thought that maybe the policies are

just for the managers, that is maybe District Managers but we discovered that these policies has to go down even to our

members whom we are supervising and we realized that most of our members are not aware of our policies so from the

hub meeting we thought and discussed it and right know at least we are implementing to the others. We are creating

awareness to our colleagues. (FGD 2)

To increase their level of involvement, participants mentioned that they require more knowledge and skills in policy

issues. They also do recognized the involvement of different stakeholders to provide capacity building on policy issues.

…….I believe if we are to get started in policy issues then serious training of nurses in policy development,

implementation and review or adjustments issues is required…….(FGD 1)

Different kinds of assistance are also needed for us to effectively be part of the development process…. For instance

government bodies, NGOs and community are important stakeholders (FGD 3).

3.2 Nurses perceptions about involvement in policy development.

Study participants perceived involvement in policy development on two distinct levels: that of policy formulation,

which they associated with education levels; and that of policy implementation which was linked to less knowledge

and skills. They mentioned that they feel intimidated by other health professions especially the doctors who they



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presume to be more learned and are in a better position to understand policy issues. This is evident in the participants’

sentiments as below:

For a long time, nurses have been involved in policy implementation process and this is because we have limited

knowledge on policy issues, therefore my take is that our skills in policy issues need to be improved. (FGD 2)

Doctors are the main players in policy development. Truth be told they have more knowledge being their training is

more elaborate than ours. (FGD 3)

Although participants associate nurses’ involvement in policy development to improvement in nursing care, they still

lack the confidence and interest to be involved in the process. Many participants mentioned that negative attitude and

lack of interest towards policy development bar them for participating.

Nurses are very busy people and at times we don’t even have time to get involved in policy issues. And again when you

are in forums with doctors then you feel you have less opinions or suggestions. (FGD1)

For a long time nurses have been care givers and therefore changing this practice and starting to be involved in policy

in my own view I don’t think we are ready enough our confidence needs to be built (FGD 2)

3.3 Benefits of Hubs Involvement in policy development

This category has four main sub categories that explain benefits mentioned by the Hub nurses for their involvement in

policy development process and those factors that support their involvement in policy development.

3.3.1 Improved nursing care

Participants appreciated that although they have been involved in policy development issues at the local district and

sub districts levels and at their workplaces, they have seen some improvement in the nursing care for their clients,

themselves and even for the organization. This is evident in the quotes below

With the little we have been involved in policy issues, our clients are starting to be very happy, when they see that you

are able to take more time with them and explaining further their conditions to them they become happy. (FGD 2)

The service chatter is a policy. But it doesn’t work well in all setting therefore we have made small adjustments at our

local facilities and patients are able to understand why they pay certain amounts of money for treatment which makes

our work as nurses much more easy. (FGD 1)

In addition other factor that has improved the nursing care is support from their work places. It was highlighted by

participants that support is necessary if change is to be realized and that the most important support is that from the

workplace both from the employer and colleagues.

Okay what I would say is that my employer has a positive response, number one; right now as am sited here am

supposed to be on duty, but permission has been granted so that I may attend the hub meeting, that is number one

involvement. Another thing, I think the employer is also working in collaboration with the GLUK, and that is why we

are sited here, and sometimes once in a while as we go out we usually consult with our immediate supervisors, those

are our employers. So all in all I think they are having positive response towards the Hub project. (FGD 1)

Further, nurses have got support from different levels of the health systems which has enhanced nursing care. They

have built relationships with different health professions who have embraced them and recognised them in policy

development process at the local levels.



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What we can add on what we have said is that in a way or another in our areas of work we have partners E.g. CDC,

FACES, Tuungane and many others carrying out a research or partners within our department who have helped us

with policy issues. (FGD 2)

We have stakeholders forum where there are different caders of people from the health offices who are there and

listens to us, so I think that is one of the thing we have been doing but as hub member as just as I said we are at initial

stages to head towards where we are interested in going. Okay. (FGD 3)

Team work and commitment has been incorporated among the nurses and they recognised that through this they are

able to share different experiences at their places of work which inform policies.

Originally when we began we did not sit together, but today we know each other, we know what the other members of

the other Hubs are doing and what they think about policy issues, even away from the common meetings we do

communicate on phones and by email. (FGD 3)

Within the hub we discussed common features, and also we work as a team with them and share what policies work

best for us in our separate work station which has been a success and what we can adopt and learn from each other.

(FGD 1)

3.4 Linkages and collaborations:

This category looked at the linkages and collaborations created by hub members during their involvement in policy

development. There are 4 sub category identified in this sections which includes linkages with government

departments, NGOs, community and learning organizations.

3.4.1 Government Departments:

This sub-category focused on how the Hub nurses have created linkages with the government of Kenya, specifically

the Ministry of Health and the Nursing Council of Kenya in influencing their involvement in policy development.

Participants highlighted that the government is the first focal body in policy development. In their view, policies are

governed by the government. They acknowledged that the government has provided support in various fields in health

promotion in terms of care and management but their participation in policy development is still very minimal. They

are still more recognized in policy implementation than policy formulation. However they mentioned that the

government should spearhead the training of nurses.

Our government has worked round the clock to ensure things are running in the facilities. They have provided the

necessary support that we need as nurses but one thing is still missing we have remained care givers for all the years

our skills is developed through the various workshops, even on policy matters they are trying to involve us but just to a

small extent. (FGD 3)

Our government is trying to involve us in one way or another being the key players in health policy issues they have up

to this point provided financial, capacity building and even social support in policy issues. (FGD 1)

3.4.2 Non-Governmental Organizations:



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International bodies have been recognized as the key funders in HIV and AIDS. This category looked at the key

contributions made by the NGOs in terms of resource, trainings and capacity building of health care workers. Some of

the highlighted participants’ sentiments are mentioned below:

We have convened with FACES, FACES is a family AIDS care education services. It is an NGO dealing with AIDS

prevention, treatment and care, so I just think that thing which was mentioned that digging more information in

HIV/AIDS, FACES was quite much supportive in terms of giving such kind of information when it was required. (FGD

1)

FACES has also helped with funds to purchase more ARVs, apart from that they also supported vulnerable families

and this is done through our facilities. So I think in terms of collaboration and networks, I think it is one of the local

NGOs which the group has gained from. (FGD 2)

3.4.3 Learning institutions:

Learning Institutions are also recognized by participants as key collaborators. Mentioned is that colleges and

universities as relevant learning institutions. Participants appreciated the collaborations they have created with various

learning institutions. This is evident in their sentiments below:

We were privileged to have a lecturer from Great Lakes University. GLUK has provided a lot of support in terms of

capacity building on policy issues. They have also helped us a lot in developing our evaluation projects. They have

developed our skills and capacity in research. And now at least each one of us knows some competent of research.

(FGD 2)

We have had the opportunity to collaborate with even bigger institutions; the University of Ottawa has been a great

collaborator they have fully supported the project and even provided the best capacity to us. I think this has really

benefited us. (FGD 3)

3.4.4 Community

There is recognition by the participants that community members need to be involved in the policy making process.

The community members, participants mentioned includes community based organizations, church groups and

schools. They recognized that there is a linkage between the community and Ministry of Health.

Although some of us may say there is no true linkage between the ministry of health and the community, I think there is

linkage between them and at least we are networking; we are networking with the community at different levels for

instance we do health education and health campaigns at the community. We also go to schools to provide education

on safe sex and organize health talks at the churches therefore I think we have networked. (FGD 3)

This Hub meeting has also helped us create linkages with the community. In the Hub the community is somehow

represented. And I think once there is a representation from the community, we are gaining more from the community

and intern, the representatives from the community are also going to give feed backs to the community, in return we are

going to achieve our goals at the end of it. (FGD 2)

3.5 Knowledge and skills

This sub category looked at the knowledge and skills the participants have acquired during their involvement in policy

development. Participants mentioned capacity building at different levels that include policy issues, research skills and

general skills they have acquired in the involvement in policy development



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Participants mentioned that they have acquired skills in policy issues including policy making processes. The processes

they mentioned include policy identification, policy formulation, policy adoption, implementation and evaluation.

These are evident in the following quotes

In our involvement in policy process, we have learnt a lot. Personally I have learnt that policy making is a long process

it involves formation, implementation and evaluation. (FGD 1)

From the various workshops we have attended, policy issues are not a small thing is requires adequate skills. So far we

have had forums on policy identification, formation, implementation and evaluation which I believe is a good starting

point. (FGD 2)

Participants also mentioned that they have acquired a lot of research skills in terms of proposal development in their

engagement in policy issues. Participants recognized that it is through research that nurses will identify policy issues

which will enhance their participation in policy formulation issues. They continued to state that research is not all about

data collection as they have been involved in before but should incorporate issues of data analysis and dissemination of

findings.

These sentiments are evident in the following quotes:

As much as my colleagues will be having ideas on research, this is an area where majority may need to revisit, however

we have learnt so much. We have learnt issues of problem identification, literature review, various methods used in

conducting research and so many much more. I believe we have learnt a lot. (FGD 2)

Yeah I agree with my colleagues, what I could like to add is that we have also learnt about proposal development,

data collection methods, how to analyze data and even disseminate the finds this hub has really built our capacity.

(FGD 1)

Participants also mentioned that they have acquired general skills that have helped manage their workplaces in a much

organized way. The general skills mentioned included financial management, leadership skills, and project monitoring

and evaluation and negotiation skills.

“Because I see the world is changing and people are becoming more advanced therefore we must change with the

world, therefore the skills we have got in management issue will help us influence our involvement in policy issues.

(FGD 2)

“I don’t know if the rest of my colleagues have the same feeling but they would agree with me that this hub meeting

have helped us gain so much in terms of skills, we have worked with an organized group and therefore we must be

organized ourselves, I have learnt good leadership skills from this hub activity, I have got something on project

management and even how to negotiate for research funding.

3.6 Barriers to policy development

This category emphasized on barriers to involvement in policy development theses are perceived to be governed by

both internal and external factors.

3.6.1 Internal Factors

It is mentioned that the workplace shapes the activities of their employees. A number of issues were expressed by the

participants to include competing priorities, time factor, work schedules, leadership and management as internal



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factors. Most frequently highlighted however was competing priorities. Participants mentioned that one might be

interested in being part of change but other activities become a hindrance. This is evident in the two quotes below.

We as nurses have an objective of providing care to our patients. At times it becomes so difficult for me to go and

attend a meeting while my client is so much in need of help. So in this case my priority is to attend to my sick client and

that is the order of the day here, your client first. Even when you want to delegate your duties it’s not every day that you

will find someone to step in for you. (FGD 1)

we have what we are doing in our various places of work. With the shortage of nurses in our facilities, You find that a

meeting has been called and you have a duty that you must first accomplish, so you have to squeeze time so as to meet

all the goals.(FGD 2)

3.6.2 External factors

The meanings derived from the narratives that formed this category focused on factors that are beyond a given

participant’s workplace, but which have an influence on involvement of participants in policy development. These

were factors that were beyond the control of the participants and were shaped majorly by the national levels.

The participants indicated that policies are still restricted to top down approach where key government officials take

the lead role in policy development. Participants continued to highlight that at this point their role in policy

development is very limited. Therefore the perception among participants was that as long as the officials continue to

be the lead in policy development, nurses’ contribution will remain minimal.

I know policies are made in parliament with key officer from the ministry of health, in the process of making it to reach

parliament there are many changes that take place along the way. So I think the structure is poor so that by the time it

reaches the parliament to be debated upon the information which favors nurses to participate fully is not mentioned.

(FGD 3)

In my view, policy is still being made by people up there, and so they do it as they used to do it before, they carry out

their own research and do it there without us being involved that is my view (FGD 1)

Another key external factor frequently cited by the participants as a hindrance to involvement in policy development

was the resistance to change by the health policy makers. There was a perception among participants that policy

makers are rigid and any change is not easily welcomed by government officials.

I think it’s quite a good thing that Teasdale Corti in collaboration with GLUK has trained us and empowered us to

carry out research, the only gap I see in future is rejection by the policy makers, where nurses want to take part in

policy development might not be easy, you see the truth is that policy making is left for higher health professional, even

with the findings we already have, it will take years before our managers can accept change so it will still be difficult to

see nurses participate in policy making. (FGD 3)

Also I think one area which challenging aspect is that this policy dissemination, formulation of implementation it may

be a new culture to our society because in most cases it is left for us I appreciate on what my boss says. (Laughing) in

most cases reality of the matter the policy dissemination is most cases left for the Head of the institution and if the head

of institution is not interested most of the aspect this thing hardly happen so you find head of department just follow the

activities and activities may not necessarily mean policy of dissemination, so the fact that it is a new culture you find

that you are sort of odd what you are trying to say is new to people so they feel as if it is something impossible(FGD 2)



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Lastly mentioned by the participants were the inadequate resources and infrastructures as another factor that slows

down nurses’ involvement in policy development. However participants were quick to recognize that attitudes of the

policy makers must first be addressed before resources can be availed to carry out research that will influence policy

making. In addition, participants mentioned that continuous empowerment of nurses to be involved in research was

important. There’s need for better educational preparation and an environment that support research.

I just wanted to talk on policies they are published, the pamphlets are very few, you find in a District they could even

send copies about two to three copies of the policies so we could make it in such a way that these policies copies reach

the ground up to probably dispensary or we make it a policy that each member of staff gets a copy of the policy and

maybe that is when they can understand but when you bring three copies and put it to the… send it to the MOH it is

not… it is rear that it will reach everybody, so enough copies should be emphasized (FGD 1)

I would also say lack adequate staffs within our working areas also plays a role. you may be forced to go and feel the

gap somewhere because of shortages that is another reason that has made it cumbersome for us to come to meetings in

time yet its through such meeting that we have learn about necessary steps we can take to be involved in policy making

but staff shortage will still be with us. (FGD 3)

4. Discussion

In the introduction, the researcher highlighted the need for more nurses to be involved in policy development (Pan

American Health Organization, 2004), arguing that given their constant presence with patients, they are better placed

to identify gaps in nursing care (Kleinpell, 2003).The researcher therefore sought to find out the level of hub nurses

involvement in policy development, benefits of their involvement and barriers of their involvement in policy

development process. In the discussion, the researcher has highlighted key issues that emerged from the data.

4.1 Level of involvement in policy development

There is need to acknowledge the partial involvement of nurses in policy issues at the different levels of the health care

systems. It is important to appreciate the recognition that nurses are able get from their places of work. However it is

clear from the findings that involvement of nurses in policy development is still very limited. It is still rooted at the

local levels to include the community, sub district and district levels. Participation at the national and provincial levels

is presumed to be for more educated health professionals. Consistent with WHO report (2001), The Global Advisory

Group on Nursing and midwifery highlighted the need for nurses and midwives to formulate health care policy at

country, district, sub-district and local levels for improving national health services.

4.2 Benefits to their involvement in policy issues

Nurses are able to clearly relate nursing involvement in policy development to improving nursing care which is related

to the ICN suggesting that nurses can make an imperative contribution to the development of appropriate and effective

health policy when they are included in the process of policy formulation. (International Council of Nurses, 2008). The

ICN strongly promotes and supports efforts to improve the preparation of nurses for policy development which in turn

improves the nursing care.

Motivation is another factor in the aspects of participation in policy development. Knowledge and skills in policy

issues is one of the motivating factors to engage nurses into policy matters. Through acquired knowledge and skills,

nurses are empowered not only to implement policies but also be part of the policy formulation. This argument is in



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line with McKinsey 2001, who emphasizes that in any development process, different elements of the triangle are all

connected and integrated. In his study the 3 aspects of a triangle must join together to form a whole hence cooperation.

A number of studies stress the need for workplace support for the purpose of increasing involvement of nurses in policy

development activities (Albers & Sedler, 2000 ). They suggest that it is fundamental for all healthcare settings to

develop and maintain a visible engagement of nurses in policy development. Important to note is that participants

appreciate and acknowledges the support they have received from their work places. They mention that support from

both the employer and fellow colleagues is necessary if change is to be realized and if health care services are to be

improved.

Linkages are other important aspects that contribute to participation in policy issues. Training elements is necessary for

the empowerment and engagement in policy formulation. This is in line with the studies by Rafferty’s (2003) who

comment that there is need to introduce the fundamentals health policy in both Bachelor’s and Diploma programs for

nursing students. This perception is also in line with those reported by other authors (Askew et al., 2002), effectively

stressing the need for better educational preparation for nursing .

4.3 Barriers to involvement

Limited knowledge and skills in policy development is regarded as a hindrance into policy making process. Other

authors consent that knowledge on policy issues is an important prerequisite for participation of nurses in policy issues

(McNicholl et al., 2008). The significance of capacity building in policy making process has been addressed by a

number of health scientists (Costello & Zumla, 2000). The need for protected time to engage in policy formulation

has been singled out in many studies as being fundamental if organizations are to build a policy development culture

(McNicholl et al., 2008). Competing priorities and limited time is another key hindrance to nurses’ participation in

policy development process. Consistent with this argument is that nurses are at the forefront caring for the patients and

their families who shoulder significant responsibility for their continuing treatment and care (Pan-American Health

Organization, 2004).

External factors are also restrict nurses from fully participating in policy formulation processes. These are beyond the

control of working environments and are usually shaped at the national levels. These factors include policy formulation

processes which are controlled at the parliamentary levels and still exist within a top-down approach. Inadequate

resources and infrastructures also hinder nurses’ participation. Consistent with WHO Report 2003 which recognizes

that despite numerous recommendations from international and regional bodies to include nurses as participants at all

levels of health system, numerous factors contribute to the absence of nurses from health systems decision-making.

Chief among these factors are poor working conditions, lack of professional status, excessive workload, and the fact

that policy makers are resistant to change perpetuating the top-down approach to policy formulation and

implementation.

5. Conclusion

Health policy not only impacts the profession of nursing on multiple levels but also affects the population in general.

Nurses’ are in a unique position to influence the formation and implementation of health policy and in that way impact

on their profession and the health of the population. Therefore nurses’ are encouraged to participate in policy

development yet their involvement is shaped by a number of factors that must be addressed. The most important of

these is capacity building of nurses for effective participation in policy development processes. In addition, increasing

the number of benefits nurses perceive to have in participating in health policy activities may increase their interest in

health policy and hence their involvement. Decreasing the number of barriers nurses experience in being involved may

also have a positive effect on nurses’ level of involvement. All these actions to improve nurses’ participation can be

achieved through linkages and collaborations as demonstrated by the leadership hubs, bringing together government

bodies, NGOs, learning institutions and the community to address barriers to their participation.



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